White Rock Medical Center

All Charges

Charge

Type

Setting

Price

HEADLESS SCREW 2.5MM X 36MM DART-FIRE COMPRESSION SCREW

Facility

$1,596.99

Service Code	HCPCS C1713
Hospital Charge Code	992399
Hospital Revenue Code	278
Min. Negotiated Rate	$143.73
Max. Negotiated Rate	$1,149.83
Rate for Payer: Amerigroup CHIP/Medicaid	$143.73
Rate for Payer: BCBS of TX Blue Advantage	$479.10
Rate for Payer: BCBS of TX Blue Essentials	$574.92
Rate for Payer: BCBS of TX PPO	$638.80
Rate for Payer: Cash Price	$1,085.95
Rate for Payer: Cigna Medicaid	$1,149.83
Rate for Payer: Molina CHIP/Medicaid	$1,149.83
Rate for Payer: Multiplan Auto	$798.50
Rate for Payer: Multiplan Commercial	$798.50
Rate for Payer: Multiplan Workers Comp	$798.50
Rate for Payer: Parkland Medicaid	$1,149.83
Rate for Payer: Scott and White EPO/PPO	$798.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,149.83
Rate for Payer: Superior Health Plan EPO	$217.19

HEADLESS SCREW 2.5MM X 36MM DART-FIRE COMPRESSION SCREW

Facility

$1,596.99

Service Code	HCPCS C1713
Hospital Charge Code	992399
Hospital Revenue Code	278
Min. Negotiated Rate	$399.25
Max. Negotiated Rate	$798.50
Rate for Payer: Cash Price	$1,085.95
Rate for Payer: Cigna Commercial	$399.25
Rate for Payer: Multiplan Auto	$798.50
Rate for Payer: Multiplan Commercial	$798.50
Rate for Payer: Multiplan Workers Comp	$798.50
Rate for Payer: Scott and White EPO/PPO	$798.50

HEADLESS SCREW 3.0MM X 24MM

Facility

$2,410.00

Service Code	HCPCS C1713
Hospital Charge Code	145141
Hospital Revenue Code	278
Min. Negotiated Rate	$216.90
Max. Negotiated Rate	$1,735.20
Rate for Payer: Amerigroup CHIP/Medicaid	$216.90
Rate for Payer: BCBS of TX Blue Advantage	$723.00
Rate for Payer: BCBS of TX Blue Essentials	$867.60
Rate for Payer: BCBS of TX PPO	$964.00
Rate for Payer: Cash Price	$1,638.80
Rate for Payer: Cigna Medicaid	$1,735.20
Rate for Payer: Molina CHIP/Medicaid	$1,735.20
Rate for Payer: Multiplan Auto	$1,205.00
Rate for Payer: Multiplan Commercial	$1,205.00
Rate for Payer: Multiplan Workers Comp	$1,205.00
Rate for Payer: Parkland Medicaid	$1,735.20
Rate for Payer: Scott and White EPO/PPO	$1,205.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,735.20
Rate for Payer: Superior Health Plan EPO	$327.76

HEADLESS SCREW 3.0MM X 24MM

Facility

$2,410.00

Service Code	HCPCS C1713
Hospital Charge Code	145141
Hospital Revenue Code	278
Min. Negotiated Rate	$602.50
Max. Negotiated Rate	$1,205.00
Rate for Payer: Cash Price	$1,638.80
Rate for Payer: Cigna Commercial	$602.50
Rate for Payer: Multiplan Auto	$1,205.00
Rate for Payer: Multiplan Commercial	$1,205.00
Rate for Payer: Multiplan Workers Comp	$1,205.00
Rate for Payer: Scott and White EPO/PPO	$1,205.00

HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE

Facility

$13,407.94

Service Code	APR-DRG 0554
Min. Negotiated Rate	$12,641.47
Max. Negotiated Rate	$13,407.94
Rate for Payer: Amerigroup CHIP/Medicaid	$12,641.47
Rate for Payer: Cigna Medicaid	$12,641.47
Rate for Payer: Molina CHIP/Medicaid	$12,641.47
Rate for Payer: Parkland Medicaid	$12,641.47
Rate for Payer: Superior Health Plan CHIP/Medicaid	$13,407.94

HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE

Facility

$4,919.68

Service Code	APR-DRG 0552
Min. Negotiated Rate	$4,638.44
Max. Negotiated Rate	$4,919.68
Rate for Payer: Amerigroup CHIP/Medicaid	$4,638.44
Rate for Payer: Cigna Medicaid	$4,638.44
Rate for Payer: Molina CHIP/Medicaid	$4,638.44
Rate for Payer: Parkland Medicaid	$4,638.44
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,919.68

HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE

Facility

$2,905.49

Service Code	APR-DRG 0551
Min. Negotiated Rate	$2,739.39
Max. Negotiated Rate	$2,905.49
Rate for Payer: Amerigroup CHIP/Medicaid	$2,739.39
Rate for Payer: Cigna Medicaid	$2,739.39
Rate for Payer: Molina CHIP/Medicaid	$2,739.39
Rate for Payer: Parkland Medicaid	$2,739.39
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,905.49

HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE

Facility

$7,399.69

Service Code	APR-DRG 0553
Min. Negotiated Rate	$6,976.69
Max. Negotiated Rate	$7,399.69
Rate for Payer: Amerigroup CHIP/Medicaid	$6,976.69
Rate for Payer: Cigna Medicaid	$6,976.69
Rate for Payer: Molina CHIP/Medicaid	$6,976.69
Rate for Payer: Parkland Medicaid	$6,976.69
Rate for Payer: Superior Health Plan CHIP/Medicaid	$7,399.69

HEALIX ADV HARD BONE KIT

Facility

$2,460.68

Hospital Charge Code	992661
Hospital Revenue Code	272
Min. Negotiated Rate	$221.46
Max. Negotiated Rate	$1,771.69
Rate for Payer: Amerigroup CHIP/Medicaid	$221.46
Rate for Payer: BCBS of TX Blue Advantage	$738.20
Rate for Payer: BCBS of TX Blue Essentials	$885.84
Rate for Payer: BCBS of TX PPO	$984.27
Rate for Payer: Cash Price	$1,673.26
Rate for Payer: Cigna Medicaid	$1,771.69
Rate for Payer: Molina CHIP/Medicaid	$1,771.69
Rate for Payer: Multiplan Auto	$1,599.44
Rate for Payer: Multiplan Commercial	$1,599.44
Rate for Payer: Multiplan Workers Comp	$1,599.44
Rate for Payer: Parkland Medicaid	$1,771.69
Rate for Payer: Scott and White EPO/PPO	$1,230.34
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,771.69
Rate for Payer: Superior Health Plan EPO	$334.65

HEALIX ADV HARD BONE KIT

Facility

$2,460.68

Hospital Charge Code	992661
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,673.26

HEART AND/OR LUNG TRANSPLANT

Facility

$57,475.31

Service Code	APR-DRG 0023
Min. Negotiated Rate	$54,189.73
Max. Negotiated Rate	$57,475.31
Rate for Payer: Amerigroup CHIP/Medicaid	$54,189.73
Rate for Payer: Cigna Medicaid	$54,189.73
Rate for Payer: Molina CHIP/Medicaid	$54,189.73
Rate for Payer: Parkland Medicaid	$54,189.73
Rate for Payer: Superior Health Plan CHIP/Medicaid	$57,475.31

HEART AND/OR LUNG TRANSPLANT

Facility

$35,763.18

Service Code	APR-DRG 0021
Min. Negotiated Rate	$33,718.77
Max. Negotiated Rate	$35,763.18
Rate for Payer: Amerigroup CHIP/Medicaid	$33,718.77
Rate for Payer: Cigna Medicaid	$33,718.77
Rate for Payer: Molina CHIP/Medicaid	$33,718.77
Rate for Payer: Parkland Medicaid	$33,718.77
Rate for Payer: Superior Health Plan CHIP/Medicaid	$35,763.18

HEART AND/OR LUNG TRANSPLANT

Facility

$46,171.71

Service Code	APR-DRG 0022
Min. Negotiated Rate	$43,532.30
Max. Negotiated Rate	$46,171.71
Rate for Payer: Amerigroup CHIP/Medicaid	$43,532.30
Rate for Payer: Cigna Medicaid	$43,532.30
Rate for Payer: Molina CHIP/Medicaid	$43,532.30
Rate for Payer: Parkland Medicaid	$43,532.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$46,171.71

HEART AND/OR LUNG TRANSPLANT

Facility

$233,355.14

Service Code	APR-DRG 0024
Min. Negotiated Rate	$220,015.40
Max. Negotiated Rate	$233,355.14
Rate for Payer: Amerigroup CHIP/Medicaid	$220,015.40
Rate for Payer: Cigna Medicaid	$220,015.40
Rate for Payer: Molina CHIP/Medicaid	$220,015.40
Rate for Payer: Parkland Medicaid	$220,015.40
Rate for Payer: Superior Health Plan CHIP/Medicaid	$233,355.14

HEART FAILURE

Facility

$12,327.67

Service Code	APR-DRG 1944
Min. Negotiated Rate	$11,622.96
Max. Negotiated Rate	$12,327.67
Rate for Payer: Amerigroup CHIP/Medicaid	$11,622.96
Rate for Payer: Cigna Medicaid	$11,622.96
Rate for Payer: Molina CHIP/Medicaid	$11,622.96
Rate for Payer: Parkland Medicaid	$11,622.96
Rate for Payer: Superior Health Plan CHIP/Medicaid	$12,327.67

HEART FAILURE

Facility

$4,978.89

Service Code	APR-DRG 1943
Min. Negotiated Rate	$4,694.28
Max. Negotiated Rate	$4,978.89
Rate for Payer: Amerigroup CHIP/Medicaid	$4,694.28
Rate for Payer: Cigna Medicaid	$4,694.28
Rate for Payer: Molina CHIP/Medicaid	$4,694.28
Rate for Payer: Parkland Medicaid	$4,694.28
Rate for Payer: Superior Health Plan CHIP/Medicaid	$4,978.89

HEART FAILURE

Facility

$3,250.99

Service Code	APR-DRG 1942
Min. Negotiated Rate	$3,065.15
Max. Negotiated Rate	$3,250.99
Rate for Payer: Amerigroup CHIP/Medicaid	$3,065.15
Rate for Payer: Cigna Medicaid	$3,065.15
Rate for Payer: Molina CHIP/Medicaid	$3,065.15
Rate for Payer: Parkland Medicaid	$3,065.15
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,250.99

HEART FAILURE

Facility

$2,464.55

Service Code	APR-DRG 1941
Min. Negotiated Rate	$2,323.67
Max. Negotiated Rate	$2,464.55
Rate for Payer: Amerigroup CHIP/Medicaid	$2,323.67
Rate for Payer: Cigna Medicaid	$2,323.67
Rate for Payer: Molina CHIP/Medicaid	$2,323.67
Rate for Payer: Parkland Medicaid	$2,323.67
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2,464.55

HEART FAILURE AND SHOCK WITH CC

Facility

$16,393.20

Service Code	MSDRG 292
Min. Negotiated Rate	$7,549.50
Max. Negotiated Rate	$16,393.20
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$10,982.42
Rate for Payer: Amerigroup Medicare	$10,982.42
Rate for Payer: BCBS of TX Medicare	$10,982.42
Rate for Payer: Cigna Commercial	$10,935.12
Rate for Payer: Cigna Medicare	$10,982.42
Rate for Payer: Employer Direct Commercial	$10,982.42
Rate for Payer: Humana Medicare/TRICARE	$10,982.42
Rate for Payer: Molina Dual Medicare/Medicaid	$10,982.42
Rate for Payer: Molina Medicare	$10,982.42
Rate for Payer: Multiplan Auto	$16,393.20
Rate for Payer: Multiplan Commercial	$16,393.20
Rate for Payer: Multiplan Workers Comp	$16,393.20
Rate for Payer: Scott and White EPO/PPO	$7,549.50
Rate for Payer: Scott and White Medicare	$10,982.42
Rate for Payer: Superior Health Plan EPO	$10,982.42
Rate for Payer: Superior Health Plan Medicare	$10,982.42
Rate for Payer: Universal American Dual Medicare/Medicaid	$10,982.42
Rate for Payer: Universal American Medicare	$10,982.42
Rate for Payer: Wellcare Medicare	$10,982.42
Rate for Payer: Wellmed Medicare	$10,982.42

HEART FAILURE AND SHOCK WITH MCC

Facility

$24,316.20

Service Code	MSDRG 291
Min. Negotiated Rate	$11,198.25
Max. Negotiated Rate	$24,316.20
Rate for Payer: Employer Direct Commercial	$14,169.09
Rate for Payer: Humana Medicare/TRICARE	$14,169.09
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$14,169.09
Rate for Payer: Amerigroup Medicare	$14,169.09
Rate for Payer: BCBS of TX Medicare	$14,169.09
Rate for Payer: Cigna Commercial	$16,535.34
Rate for Payer: Cigna Medicare	$14,169.09
Rate for Payer: Molina Dual Medicare/Medicaid	$14,169.09
Rate for Payer: Molina Medicare	$14,169.09
Rate for Payer: Multiplan Auto	$24,316.20
Rate for Payer: Multiplan Commercial	$24,316.20
Rate for Payer: Multiplan Workers Comp	$24,316.20
Rate for Payer: Scott and White EPO/PPO	$11,198.25
Rate for Payer: Scott and White Medicare	$14,169.09
Rate for Payer: Superior Health Plan EPO	$14,169.09
Rate for Payer: Superior Health Plan Medicare	$14,169.09
Rate for Payer: Universal American Dual Medicare/Medicaid	$14,169.09
Rate for Payer: Universal American Medicare	$14,169.09
Rate for Payer: Wellcare Medicare	$14,169.09
Rate for Payer: Wellmed Medicare	$14,169.09

HEART FAILURE AND SHOCK WITHOUT CC/MCC

Facility

$10,645.70

Service Code	MSDRG 293
Min. Negotiated Rate	$4,902.62
Max. Negotiated Rate	$10,645.70
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$8,908.30
Rate for Payer: Amerigroup Medicare	$8,908.30
Rate for Payer: BCBS of TX Medicare	$8,908.30
Rate for Payer: Cigna Commercial	$7,290.08
Rate for Payer: Cigna Medicare	$8,908.30
Rate for Payer: Employer Direct Commercial	$8,908.30
Rate for Payer: Humana Medicare/TRICARE	$8,908.30
Rate for Payer: Molina Dual Medicare/Medicaid	$8,908.30
Rate for Payer: Molina Medicare	$8,908.30
Rate for Payer: Multiplan Auto	$10,645.70
Rate for Payer: Multiplan Commercial	$10,645.70
Rate for Payer: Multiplan Workers Comp	$10,645.70
Rate for Payer: Scott and White EPO/PPO	$4,902.62
Rate for Payer: Scott and White Medicare	$8,908.30
Rate for Payer: Superior Health Plan EPO	$8,908.30
Rate for Payer: Superior Health Plan Medicare	$8,908.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$8,908.30
Rate for Payer: Universal American Medicare	$8,908.30
Rate for Payer: Wellcare Medicare	$8,908.30
Rate for Payer: Wellmed Medicare	$8,908.30

HEART FAILURE & SHOCK W CC

Facility

$16,393.20

Service Code	MSDRG 292
Min. Negotiated Rate	$7,549.50
Max. Negotiated Rate	$16,393.20
Rate for Payer: BCBS of TX Blue Advantage	$7,910.28
Rate for Payer: BCBS of TX Blue Essentials	$9,491.42
Rate for Payer: BCBS of TX PPO	$10,546.43

HEART FAILURE & SHOCK W MCC OR PERIPHERAL EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Facility

$24,316.20

Service Code	MSDRG 291
Min. Negotiated Rate	$11,198.25
Max. Negotiated Rate	$24,316.20
Rate for Payer: BCBS of TX Blue Advantage	$11,570.44
Rate for Payer: BCBS of TX Blue Essentials	$13,883.18
Rate for Payer: BCBS of TX PPO	$15,426.36

HEART FAILURE & SHOCK W/O CC/MCC

Facility

$10,645.70

Service Code	MSDRG 293
Min. Negotiated Rate	$4,902.62
Max. Negotiated Rate	$10,645.70
Rate for Payer: BCBS of TX Blue Advantage	$5,724.16
Rate for Payer: BCBS of TX Blue Essentials	$6,868.33
Rate for Payer: BCBS of TX PPO	$7,631.77

HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC

Facility

$534,775.90

Service Code	MSDRG 001
Min. Negotiated Rate	$210,147.98
Max. Negotiated Rate	$534,775.90
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$210,147.98
Rate for Payer: Amerigroup Medicare	$210,147.98
Rate for Payer: BCBS of TX Medicare	$210,147.98
Rate for Payer: Cigna Commercial	$360,947.83
Rate for Payer: Cigna Medicare	$210,147.98
Rate for Payer: Employer Direct Commercial	$210,147.98
Rate for Payer: Molina Dual Medicare/Medicaid	$210,147.98
Rate for Payer: Molina Medicare	$210,147.98
Rate for Payer: Multiplan Auto	$534,775.90
Rate for Payer: Multiplan Commercial	$534,775.90
Rate for Payer: Multiplan Workers Comp	$534,775.90
Rate for Payer: Scott and White EPO/PPO	$246,278.38
Rate for Payer: Scott and White Medicare	$210,147.98
Rate for Payer: Superior Health Plan EPO	$210,147.98
Rate for Payer: Superior Health Plan Medicare	$210,147.98
Rate for Payer: Universal American Dual Medicare/Medicaid	$210,147.98
Rate for Payer: Universal American Medicare	$210,147.98
Rate for Payer: Wellcare Medicare	$210,147.98
Rate for Payer: Wellmed Medicare	$210,147.98

Know your out-of-pocket cost for care.

All Charges